Healthcare Provider Details

I. General information

NPI: 1306356969
Provider Name (Legal Business Name): MARY GRACE ANTONETTE LAVINA ABEAR PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date: 10/11/2017
Reactivation Date: 10/18/2017

III. Provider practice location address

5200 N LAKE RD
MERCED CA
95343-5001
US

IV. Provider business mailing address

PO BOX 1318
SACRAMENTO CA
95812-1318
US

V. Phone/Fax

Practice location:
  • Phone: 209-228-4266
  • Fax:
Mailing address:
  • Phone: 707-315-5406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY35685
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF100848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: